• eurico marques

Bone Stress Injuries Part 5 - Return to Running (Pinning a tail on a Donkey)

Updated: Mar 31

#Physiotherapy #InjuryPrevention #Stress #Running


Throughout this series we have unraveled the complexity of Bone Stress Injuries (BSI) and their management. Thank-you for hanging in there with me. In Part 5, we will try and pin the tail on the running donkey. Finding the optimal loading program is one of continued experimentation and adjustment. In this article, I will attempt to provide you with clarity and point you in the right direction.


So, your athlete feels good – no more pain, no longer tender to palpation and they have established a strength base even Allyson Felix would be proud of. So, what next… I guess it’s time to start running. Continuing the Road to Recovery, in this article we will discuss phase 2 of a recovery of a Low Risk Bone Stress Injury – a graded return to running/training.

Returning to Running (RTR) is most likely the scariest part for the therapist but the most exciting for the athlete. Months of agonizing rest and countless rehabilitation sessions have culminated in this moment, but where do we start? The reality is that there is no recipe but rather principles that should guide the return. As discussed earlier in this series, Bone Stress Injuries are developed through inappropriate loading strategies, but loading is also at the centre of the management plan. During RTR, the introduction of appropriate load is vital and can be defined as the amount of load that does not cause BSI symptoms either during or after the completion of the session[1].


Dividing the RTR process in blocks (i.e. set number of days/weeks/months) is a simple model on which to build a program. Depending on the athlete I will then fill these blocks with relevant information and goals for the athlete to achieve. In my experience using block periodisation provides the athlete with a clear progression and regression plan for the unpredictable process. Giving up a sense of control and empowering the athlete during this phase is vital, as for the most part their running sessions will not be done under your guidance. The athlete needs to be in control and the therapist becomes the facilitator.


Whilst a recipe for RTR is not possible, several principles have been established to assist practitioners in creating individualised programs for their athletes. I consider the principles to be a framework on which I can construct a detailed running program that suits my athlete’s biopsychosocial needs. The complexity of the individual often makes complete control difficult, thus defining the framework is beneficial.

1. Pain is the key Outcome Measure

Using pain as a guide and load monitoring over 24-48 hours post each session means that initially athlete’s sessions are constrained to once every two to three days. This should give sufficient time to assess their response and adjust the load accordingly. As pain is often the guide during this phase, it is vital to emphasize with the athlete the importance of honest self-report. Through education we can create an athlete that has self-awareness and respect for the healing process rather than one that is fearful and robotic – thus needing prescriptive guidance.


2. Establish their current tissue capacity

Deciding when to progress can be difficult at times but using 5-7 days of pain free activity appears to be a generally accepted measure for progression on to the next phase[1]. Finding the starting point is individualised and it requires experimentation on behalf of the athlete. Through the subjective assessment, we can establish their pre-injury level and using this can establish a potential starting point. Encouraging the athlete to keep an exercise diary is valuable in establishing their load capacity and offering recommendations on progress.


3. Adjust one objective measure at a time.

Once I think I have established a pre-injury level, I will ask an athlete to go for a run at a set intensity, well below their pre-injury intensity – around 1:30-2 min/km slower than their pre-injury level. Commencing running on a compliant surface is also suggested – thus grass is often the surface of choice. We are only left with one variable that needs to be adjusted – time/distance (at a set speed, time and distance will be the same). I prefer to use time – I find it easier to add set time segments rather than add distance each block. Once an athlete is running the same time as their pre-injury level, the intensity can be adjusted (1). Using a run walk strategy is a great way to gradually introduce load in short loading cycles. The walk time can be increased or decreased depending on the response to the sessions[1].


4. Don’t be afraid to regress

The adjustment of the any of the load elements is dependent on the individual’s response and provocation of BSI symptoms[1]. Should they experience symptoms they will need to regress to the previous session that did not exacerbate their symptoms.


The use of Antigravity Treadmill Training (ATT) provides an option for the reintroduction of running. ATT is performed on a treadmill in which the athlete is suspended waist down in an air-filled, pressurized chamber[1]. The pressure is adjusted to control the percentage of body weight that the athlete places on their lower limbs when running. A benefit of ATT is the ability for athletes to run at higher intensities with lower bone loading[1]. In highly competitive athletes this provides an opportunity to maintain fitness levels whilst protecting the BSI site[1].


Running gait retraining continues to attract attention in the therapeutic and sports science spheres. Selection of different techniques remains contentious and based on the hypothesis that reducing Ground Reaction Forces (GRF) may reduce bone loading several plausible techniques have been developed[1]. Research into this is on-going and the pros, cons and practical implications are tabulated below. The alteration of an athlete’s running gait pattern should not be taken lightly, and I would suggest thorough investigation into a selected technique and vigilance during any changes[1].


The development and implementation of RTR programs remains an area of continuous debate. The likely reason is the complex nature of the individual. Each athlete is unique, and their response to training is determined through the multifaceted aspects of human existence. The biological, psychological and social contexts all play a role in determining not only an individual’s risk profile, but also their interaction with the recovery process. As you seek to pin the tail, it is a good idea to understand it takes time, trust and the establishment of a mutually respectful relationship. In Part 6 we will discuss the management of high-risk BSI and wrap up the BSI series. Until then, happy miles.

  1. Management and Prevention of Bone Stress Injuries in Long-Distance Runners. Warden, S J, Davis, I S and Fredericson, M. 2014, Journal of Orthopaedic & Sports Physical Therapy, pp. 749-765.


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